Match Treatment To Severity - Managing Your Asthma: Asthma

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Match treatment to severity

The first goal of treatment is to gain control over asthma symptoms. Once you and your doctor have determined how severe your asthma is, you can tailor your treatment to level of severity.

An expert international panel of the Global Initiative for Asthma (GINA) issued guidelines to help doctors and patients manage asthma, with the goal of reducing chronic disability and premature deaths while allowing patients with asthma to lead productive and fulfilling lives.

The GINA guidelines emphasize asthma management based on control of asthma symptoms. The step-care guidelines help doctors establish each patient's current level of treatment and control, then adjust treatment to gain and maintain control. This means that asthma patients should experience no or minimal symptoms (including at night) and very infrequent flare-ups, have no limitations on their activities (including physical exercise), need rescue medications only rarely, and have near-normal lung function.

The guidelines define three levels of asthma control.

Controlled. If your asthma is controlled, it means you have achieved all of the following:

• daytime symptoms twice or less per week

• no limitation of activities

• no nighttime symptoms or awakening

• need for reliever or rescue treatment no more than twice per week

• normal lung function

• no flare-ups.

Partly controlled. If your asthma is partly controlled, it means you have any of the following:

• daytime symptoms more than twice a week

• any limitation of activities

• any nighttime symptoms or awakening

• need for reliever or rescue treatment more than twice a week

• lung function less than 80% of predicted or personal best (if known)

• one or more flare-ups a year.

Uncontrolled. Your asthma is uncontrolled if you have three or more features of partly controlled asthma present in any week.

Treating to achieve control

Under the GINA guidelines, your current level of asthma control and treatment will determine which treatment you and your doctor select. For example, if your asthma is not controlled on your current treatment regimen, treatment should be stepped up until your asthma is under control. If your asthma control has been maintained for at least three months, your treatment can be stepped down with the aim of establishing the lowest step and dose of treatment that maintains control (see "Maintain control"). If your asthma is partly controlled, your doctor may consider an increase in treatment, depending on whether more effective options are available (such as an increased dose or an additional treatment), safety and cost of possible treatment options, and how satisfied you are with your level of asthma control.

The GINA guidelines recommend the following five steps for asthma treatment. Most patients with persistent asthma symptoms who have never been treated will start at Step 2. If you are diagnosed with severely uncontrolled asthma, treatment should begin at Step 3. At each treatment step, the doctor should provide a reliever medication (rapid-onset bronchodilator) for quick relief of symptoms. But regular use of reliever medication is one of the elements defining uncontrolled asthma and indicates that controller treatment should be increased. Reducing or eliminating the need for reliever treatment is both an important goal and a measure of success of treatment.

Step 1: As-needed reliever medication

You're a Step 1 patient if you haven't been treated for asthma before and you have occasional daytime symptoms (cough, wheeze, breathing problems twice or less per week, or less frequently if they occur at night) that last only a few hours. The treatment for most Step 1 patients consists of a rapid-acting inhaled beta-agonist, to be used as needed. Alternative treatments — a distant second choice — include an inhaled anticholinergic, short-acting oral beta-agonist, or short-acting theophylline, although they take longer to work and have a higher risk of side effects.

If your symptoms are more frequent, or worsen periodically, you'll need to move up to Step 2, which requires regular controller treatment in addition to as-needed reliever medication.

Step 2: Reliever medication plus a controller

Treatment Steps 2 through 5 combine an as-needed reliever treatment with regular controller treatment. At Step 2, a low-dose inhaled corticosteroid is recommended as the initial controller treatment for asthma patients of all ages.

Alternative controller medications include leukotriene modifiers, which may be a good choice if you are unable or unwilling to use inhaled corticosteroids, if you experience intolerable side effects such as persistent hoarseness from inhaled corticosteroid treatment.

Other options are available but not recommended for routine use as initial or first-line controllers in Step 2. These include sustained-release theophylline, which is not as effective as the above-mentioned treatments and has a higher risk of side effects, and cromolyn, which is also not as effective.

Step 3: Reliever medication plus one or two controllers

At Step 3, the recommended option is to combine a low dose of inhaled corticosteroid with an inhaled long-acting beta-agonist, either in a combination inhaler device (such as Advair or Symbicort) or as separate components. Usually the additive effect of the combination treatment is sufficient. But if you don't get your asthma under control within three or four months, your doctor may increase the dose of the steroid.

Other treatment options at this stage include:

• A medium dose of inhaled corticosteroid. If you are using a medium or high dose of inhaled corticosteroid delivered by a pressurized metered-dose inhaler, using a spacer device will improve delivery of the medication to your airways and reduce side effects (see "Spacers").

• A combination of a low-dose inhaled corticosteroid with a leukotriene modifier.

• A combination of a low-dose inhaled corticosteroid with a low dose of sustained-release theophylline.

Step 4: Reliever medication plus two or more controllers

If your asthma hasn't been controlled on Step 3 treatments, you should see a health professional with expertise in the management of asthma who can determine whether you are suffering from something other than asthma, or find the causes of your asthma.

The preferred treatment at Step 4 is to combine a medium or high dose of inhaled corticosteroid with a long-acting inhaled beta-agonist. However, in most patients, increasing from a medium dose to a high dose of inhaled corticosteroid provides relatively little additional benefit. The high dose is recommended only on a trial basis for three to six months when your asthma cannot be controlled with a medium-dose inhaled corticosteroid combined with a long-acting beta-agonist. Many patients with asthma of this severity are prescribed "triple-controller" therapy: inhaled corticosteroid, long-acting inhaled bronchodilator, and leukotriene modifier.

Prolonged use of high-dose inhaled corticosteroids can increase the risk of side effects. Also at medium and high doses, you need to use your inhaled corticosteroids at least twice daily.

Step 5: Reliever medication plus additional controller options

For people with allergic asthma (determined by skin or blood tests), adding injections of the anti-IgE antibody omalizumab (Xolair) to other controller medications has been shown to improve control of allergic asthma when other options haven't worked. Although omalizumab is quite effective for some people, it is costly.

Adding oral corticosteroids to other controller medications may be effective but can cause severe side effects and should be considered only if your asthma remains severely uncontrolled on Step 4 medications — meaning you are still experiencing daily limitation of your activities and frequent flare-ups.

Last updated:	September 27, 2007